Jasna Gora Residential Care Home

We found the following examples of good practice.

There were clear procedures for ensuring visitors to the home supported good infection prevention and control practice, with separate entrances used for different types of visitors.

The home was clean and well maintained with robust regimes in place to promote good hygiene practices.

There was very good oversight of the rigorous practices in the home used to prevent the spread of infection.

People's social, emotional and psychological well-being was supported so they did not feel socially isolated during the COVID-19 pandemic.

People’s experience of using this service: People told us they received safe care and were happy living there. There were enough staff to meet people’s needs. Medicines were managed safely. Staff followed infection prevention and control guidelines. Safe recruitment procedures were in place.

Staff sought people's consent before providing care and support. People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible; the policies and systems in the service support this practice. Staff training in key areas was up to date.

People were treated with kindness and compassion. Staff respected people's privacy and dignity and people were supported to be as independent as possible. Staff had built positive and caring relationships with people.

People received personalised care that was responsive to their needs and preferences. It was clear from our conversations with staff they knew people’s needs well. People knew how to make a complaint, although nobody we spoke with had any.

There were effective systems in place to monitor the quality of the care provided. People’s feedback was sought regularly and acted upon. We received positive feedback about how the service was managed.

For more details, please see the full report which is on the CQC website at www.cqc.org.uk

Rating at last inspection: Good (report published 27 October 2016).

Why we inspected: This was a planned inspection based on the previous rating.

Follow up: We will monitor all intelligence received about the service to inform the assessment of the risk profile of the service and to ensure the next planned inspection is scheduled accordingly.

Jasna Gora Residential Care Home provides care and accommodation for up to twelve, predominately Polish, older people. The home is located in a quiet residential area of Fixby, and has easy access to the local town of Huddersfield. The service is registered to support up to 12 people, and at the time of our inspection 12 people were using the service.

There was a registered manager in place. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.

Risks to people using the service were assessed and plans put in place to reduce the chances of them occurring. Regular checks were made of the premises and equipment to ensure they were safe for people to use, and accidents and incidents were safely managed. Arrangements were in place to support people in emergencies and to evacuate the building.

Medicines were managed safely. Safeguarding procedures were in place to help minimise the risk of abuse occurring. The registered manager monitored staffing levels to ensure they were sufficient to support people safely, and recruitment procedures minimised the risk of unsuitable staff being employed.

Staff received the training they needed to support people effectively and were supported through regular supervisions and appraisals. People’s rights under the Mental Capacity Act 2005 were protected.

People were supported to maintain a healthy diet and were supported to access external professionals to maintain and improve their health.

People spoke very positively about the care and support they received. People were treated with dignity and respect and staff delivered support in a kind and caring way. Staff understood the importance of protecting and encouraging people’s independence. Procedures were in place to support people to access advocacy services.

Care and support was person-centred. Care plans were regularly reviewed to ensure they accurately reflected people’s current support needs.

People were supported to access activities they enjoyed. The registered manager and staff recorded people’s participation in activities and monitored these to ensure everyone had access to something they enjoyed. Policies and procedures were in place to investigate complaints.

Staff had a clear sense of the culture and values of the service. There was a clear management structure in place, led by an effective registered manager who understood the aims of the service.

A number of quality assurance checks were carried out to monitor and improve standards at the service. Feedback was sought from people using the service through annual questionnaires and meetings. The registered manager had informed CQC of significant events in a timely way by submitting the required notifications.

At the time of this inspection Jasna Gora was providing care and support to twelve people. We spoke with seven people living at the home and reviewed information from four surveys submitted by relatives to obtain their views of the support provided. We also spoke with a visiting healthcare professional. In addition, we spoke with the home manager and two members of care staff, a cook and a domestic staff about their roles and responsibilities.

We considered all the evidence against the outcomes we inspected to help answer our five key questions; is the service safe? Is the service effective? Is the service caring? Is the service responsive? Is the service well led?

Below is a summary of what we found. If you want to see the evidence supporting our summary please read the full report.

Is the service safe?

We found all parts of the home clean with no traces of any unpleasant odours.

People who used the service told us they were treated with respect by staff and that they felt safe living in the home.

Safeguarding procedures were robust and staff understood their role in safeguarding the people they supported.

Systems were in place to make sure that managers and staff learned from events such as accidents and incidents, whistleblowing and investigations. This reduced the risks to people and helped the service to continually improve.

We found risk assessments had been undertaken to identify any potential risk and the actions required to manage the risk. This meant that people were not put at unnecessary risk but also had access to choice and remained in control of decisions about their lives.

CQC monitors the operation of the Deprivation of Liberty Safeguards which applies to care homes. While no applications had needed to be submitted, relevant policies and procedures were in place. Appropriate staff had been trained to understand when an application should be made, and how to submit one.

People were, in the main, protected against the risks associated with medicines because the provider had appropriate arrangements in place to manage medicines. One staff practice that may affect the safety of people during the administering of medication was identified and was discussed with the manager. The manager gave assurances that this issue would be addressed and staff would be given further training and support.

Is the service effective?

People and their relatives told us they were actively involved in making decisions about care and support. People's health and care needs were assessed with them and their representatives, and they were involved in writing their support plans.

Healthcare professionals we spoke with said that the staff worked well with them and followed instructions to promote and uphold people's health and welfare. They said, 'we request things that need to be carried out for residents and staff are very good at following these instructions, fluid charts and pressure area care records are always kept up to date.'

Staff were provided with training to ensure they had the skills to meet people's needs. Staff were provided with formal individual supervision and appraisals to ensure they were adequately supported and their performance was appraised. The manager and provider were accessible to staff for advice and support.

During our visit, we found people were provided with the support they needed. We found staff knew people well and were aware of their individual preferences.

Is the service caring?

We observed warm and respectful interactions between staff and people who used the service. During our inspection we observed smiling faces of both staff and people.

People who used the service were positive about the staff and felt they were known personally to them. Comments from people included, 'I am very happy here', 'staff are very good', 'no worries at all' , 'it could not be any better as we have everything we need', 'we have very good staff', 'it's very clean' and 'I would highly recommend this home to others.'

Relatives said, 'we are delighted with the care' and 'the home has a strong family ethos, very caring.'

Healthcare professionals said, 'this is one of the best homes we go into, people are treated with the utmost respect', 'no worries at all' and 'this is a home that, if we ever needed to, my colleagues all agree we would go into.'

Is the service responsive?

People were able to join in with a range of activities. We saw care workers spending time with people on a one to one basis.

People spoken with said they had never had to make a complaint but knew how to make a complaint if they were unhappy. We found appropriate procedures were in place to respond to and record any complaints received. People could be assured that systems were in place to investigate complaints and take action as necessary.

Is the service well-led?

The service worked well with other agencies and services to make sure people received their care in a joined up way.

The provider had an effective system in place to identify, assess and manage risks to the health, safety and welfare of people using the service and others.

People spoken with said they were invited to attend a 'residents meeting' which was held every month.

Staff had regular meetings with the manager and were kept updated about any information they needed to know about the service. This helped to maintain consistency in the running of the service and to ensure staff were aware of relevant information.

The provider had an effective system in place to identify, assess and manage risks to the health, safety and welfare of people using the service and others. People who used the service were asked for their views about their care and support and these were acted on.

We saw evidence that the provider carried out annual satisfaction surveys. Feedback was analysed and the provider, took appropriate action. We saw that the results of the surveys were very positive.

We looked at the care records for two people living at Jasna Gora. We found that people's needs were assessed and care and treatment was planned and delivered in line with their individual care plan.

We saw that comprehensive assessments were carried out prior to admission to Jasna Gora. We saw that staff did not keep people waiting when asked for support. This meant staff were respectful towards people who used the service and we saw that there was a good rapport between staff and people who used the service.

We saw that policies and procedures were in place in relation to receiving, administering and storing medication. This meant people were protected because the service provided instructions so that staff handled medication safely.

A robust staff recruitment process was in place, which helped to ensure that people were supported by staff members who were suitable for their required roles. From the staff records we looked at we were able to see that the staff currently working for the home had been appointed correctly.

The provider had an effective system to regularly assess and monitor the quality of service that people receive. The quality of the service was monitored through monthly internal audits.